Category Archives: Communication

Everybody appreciates it if you attempt to pronounce their name or the name of their town properly.

Here Ned Tapa helps me get my tongue around some Māori names.

Letters

There are only 15 letters in the Māori alphabet. 5 basic vowels and 10 consonants. Two of the consonants are written as digraphs (two letters representing one sound): ng and wh

Every Māori syllable finishes with a vowel.

Waka

Vowels

There are 5 basic vowels (monophthongs) and many diphthongs (combination of vowels in the same syllable)

Remember “Are there three or two?”

A as in “are”

E as in “there”

I is an e sound as in “three” (This is allegedly due to a German missionary creating the written version of the Māori language. Māori did not have a written language before the arrival of Europeans) This quirk causes a lot of mispronunciation of names and words such as Hipango which is pronounced “He-pa-ngo” not “Hi-pang-o”

O as in “or”

U as in “two”

Double vowels or a macron over a vowel, aa or ā, is a long vowel sound, so stretching out the “are” sound. As in Māori.

For a vowel combination with different vowels (diphthongs) the two sounds run together. “Tau” in Māori sounds like “toe” in English.

Consonants

Pretty much like English except for the two digraphs Ng and Wh

Ng is a nasal sound. Ng as in singer not in as finger

So Rongo is Ro ngo not Rong go

Wh is f in most of New Zealand except Whanganui and South Taranaki where wh is a breathy wh. So whanau (family) is fa nau in most parts of the country and wha nau in Whanganui and South Taranaki.

There are some other dialect differences around the country.

R is rolled, a bit like a cat’s purr, with your tongue on the roof of your mouth.

Whanganui River

Examples:

Tariana Turia (Minister of Disability Service and Associate Minister of Health)

Mere

Henare

Hohepa

Haka

Tau Henare

Ranginui

Metekingi

Patea

Rongo

Rongoa (medicine)

Hipango

Whanganui

Aramoho

Raetihi

Ohakune

Taranaki

Taumaranui

Paekakariki

Paraparaumu

Taupo

Tauranga

Some simple greetings

Kia ora is a very common greeting that means be well, and can be used for hello or thank you depending on the tone of voice.

It is from 1964. The same anaesthetists randomly treated different patients compassionately or “normally”. Opiate use was reduced by half in the first 5 days and average length of stay was reduced by 2.7 days.

It is sad we haven’t heard about this research, and that people probably won’t take it seriously as it is from “so long ago”, but Dr Youngson has plenty more evidence in his book.

We all have lots of patients everyday who need a bit of help to chill and a bit of distraction from their anxiety, depression or chronic pain.

If we refer them to mental health or the pain clinic chances are these days it is likely they will be taught how to meditate or do mindfulness exercises. These are legitimate, researched techniques and they work.

Cliff Reid from Resus.me gave this talk at Essentials of Emergency Medicine in Las Vegas today.

He discusses mastering your team, yourself and the patient. He advocates training in resus for resus, having systems to manage stress like RSI checklists

Here’s the one we use in Whanganui:

It looks complicated – because it’s a complicated process – and there is a lot to prepare and do right to make sure it goes smoothly. It also provides great documentation of what actually happened when.

Sneaky little screen shot of Cliff’s causes of shock:

[Hmm. Still gotta get sepsis, anaphylaxis and toxins in there some where.]

We need to encourage our teams to help us / challenge us / remind us of things we may have forgotten or when we are heading down the wrong track. The team leader should keep their hands off the patient and avoid becoming task focused.

Control the environment. Don’t allow the environment to control you.

We need to control the mob of helpers. Get everyone on the same page by regularly verbalising assessments and plans. We need to ask individuals to do tasks not just float a request out into the room. Different teams will be focused on their “bits” eg the surgeons on the belly. We need to keep the over view. We need to learn graded assertive techniques and to learn the science of human persuasion. Cliff sagely notes this doesn’t work well at home. Give annoying people a job eg ask the surgeon to do a cut down (while one of your team puts in the IO in a fraction of the time) 😉

We need to be comfortable with allowing patients to die with dignity when this is appropriate.

We need to learn from the cases that don’t go well. Weingart: “A good resuscitationist agonises.”

But when we do make mistakes what we do afterwards to address the mistake is important. As I’ve made plenty of mistakes I’m now getting pretty good at this 😉

So let’s look at a recent case of mine.

An 85-year-old lady with a skin tear of her shin is referred in by the wound care nurses because the wound is growing a group B strep and the wound is smelly. I’m not a great fan of wound swabs, especially in our low MRSA environment, because wound colonisation does not necessarily mean infection. An RMO / resident assessed the patient and asked me to have a look at the wound. With my bias against wound swab I went to assess the patient. Post cleaning the wound looked not too bad, it wasn’t sloughy, it didn’t smell, it had a little redness around it, it didn’t look infected but there was some dead tissue in the wound. I thought it needed debriding but not antibiotics. I debrided the wound using IV fentanyl as analgesic. The wound looked quite healthy after the debridement. I arranged for dressing and follow up next day with no antibitoics. The wound care nurse then approached me saying the woman was on immunosuppressants for her rheumatoid arthritis and needed antibiotics. I hadn’t been aware of the immunosuppresants but stubbornly persisted with my plan.

A few days later the woman returned with definite infection of the wound and ended up admitted on IV antibiotics.

In the investigation of diagnostic errors several types of errors have been described:

• Anchoring bias – locking on to a diagnosis too early and failing to adjust to new information.

• Availability bias – thinking that a similar recent presentation is happening in the present situation.

• Confirmation bias – looking for evidence to support a pre-conceived opinion, rather than looking for information to prove oneself wrong.

• Premature closure – similar to “confirmation bias” but more “jumping to a conclusion”

• Search-satisfying bias – The “eureka” moment that stops all further thought.

I anchored that this leg was not infected. We do similar things with our treatment decisions: I anchored onto my treatment plan

When first informed about this turn of events, I had that sick feeling in my stomach we all know, then I got defensive and tried to justify what I had done, but slowly I accepted what I’d done was just wrong.

So what do you do when you make mistakes?

As a junior the first thing to do is to talk to a senior

a) to let them know,

b) to get some perspective on what you have done. Some times we flog ourselves when really our mistake was only a tiny factor in what went wrong, or for the more arrogant among us we may underestimate the impact of our mistakes, and

c) so they can guide your response to this mistake. Your response will be guided by your medico-legal environment. I am lucky enough to work in New Zealand where we have a system that allows and encourages early apologies.

For a more serious case you will be going through your hospital’s complaints/patient safety system and involving your medical defense organisation and will follow their advice.

Many minor cases can be addressed with an apology to the patient. Go to the ward or phone the patient at home. The approach for exams and lawyers is to express sympathy without admitting fault: “I am sorry this has happened to you. We will be investigating what happened and will let you know the outcome.” Often, however, we know that we were wrong and the best thing to do is to acknowledge this and apologise. Patients are usually incredibly generous and forgiving. They can see you are a caring human who is actually remorseful and this does a lot to make them feel better. You were not some heartless doctor who doesn’t care that she ended up with an infected leg. If the patient does not forgive you, well at least you know where you stand and you feel a little better for trying to apologise. Most of the time though, patients do accept our apologies, as this lady did, and this is a huge weight off your shoulders and you can get on with your work without the guilt hanging over you.

Write in the patient’s notes that you have apologised, or expressed your sorrow about the patients situation without acknowledging guilt, or what ever you did:

a) this an important legal record, should this case end up in court

b) it lets the inpatient team know you have made the effort to communicate with the patient and have learned from your mistake.

Also apologise to anyone else that you need to. In this case I needed to apologise to the wound care nurse.

The case went into our hospital’s incident reporting system for further investigation as required.

Last thing is to share what you have learned with your colleagues. Hopefully you have a regular departmental meeting where cases are discussed and you are encouraged to talk about cases that went wrong and what you learned from them. If you don’t have one of these meetings make one happen! It was one of my great pleasure to arrive at my current department and find they had weekly meetings in which the discussed interesting cases and lessons learned. An environment that encourages open disclosure to patients and to colleagues is wonderful to work in – and safer for patients.